As the population in the United States diversifies, nurses have to be able to deliver care to patients who are from different cultural backgrounds. Currently, minority groups make up about 41.5% of the U.S. population (U.S. Census Bureau QuickFacts, 2018). Hispanic or Latinos make up 18.1% of the U.S. population, and 39.1% of them live in California (U.S. Census Bureau Quick Facts, 2018). It is projected that by 2044, less than 50% of the U.S. population will be non-Hispanic White individuals (Bauer & Bai, 2018).
Of concern is that the growing diversity of the U.S. population is not reflected in the nursing workforce. A 2017 survey conducted by the National Council of State Boards of Nursing and The Forum of State Nursing Workforce Centers revealed that nurses from minority background represent 19.2% of the RN workforce (Smiley et al., 2018). In terms of racial/ethnic background, the RN population is composed of 80.8% White/Caucasian; 6.2% African American; 7.5% Asian; 5.3% Hispanic; 0.4% American Indian/Alaskan Native; 0.5% Native Hawaiian/Pacific Islander; 1.7% two or more races; and 2.9% other (Smiley et al., 2018). The less than diversified workforce can lead to challenges in care delivery and communication between nurse and patient.
Problems in care delivery and communication may lead to cultural misunderstandings and thus, poor quality health care. Poor quality health care has the potential to increase costs, intensify adverse outcomes, and amplify the burden on health care systems (Kohlbry, 2016). These difficulties reinforce the need for nurses to deliver care that is culturally sensitive and culturally appropriate for the populations they serve (Kaddoura et al., 2014). Not being culturally sensitive and culturally competent can harmfully affect well-being, compliance, and restoration of health (Chen et al., 2018). Cultural sensitivity is using verbal and nonverbal language in a way that reflects understanding and appreciation of another's culture. Cultural competency is having the skills and knowledge to deliver care that is respectful and responsive to a diverse population (U.S. Department of Health and Human Services, Office of Minority Health, 2019). It must be stated that cultural competence is an ongoing process that includes accommodating and valuing differences and accepting another's worldview although it is different than one's own (Campinha-Bacote, 2019). Being culturally competent allows nurses to provide culturally specific information to patients and to ask culturally specific questions that influence health.
In the light of the changing demographics in the United States, the need for nurses to be culturally competent is clearly discernible. Developing cultural competency includes introducing nursing students to different cultures, values, and belief systems (Long, 2016). Paving the way to learn cultural competence in the nursing curriculum is a good start for students entering the nursing workforce. In 2003, the American Associations of Colleges of Nursing (2019) identified the need for cultural competency in baccalaureate nursing education. The Quality and Safety Education in Nursing (QSEN) also recognized the value of cultural competency in advancing quality health care. The QSEN organization seeks to transform nursing education where nurses are competent in the knowledge, skills, and attitudes (KSAs) that are necessary for quality patient care (QSEN, 2019). The QSEN competency also recognizes that cultural competence is vital to high-quality care and is patient centered. In supporting patient-centered care, baccalaureate nursing students should be taught the KSAs crucial to support the patient, family, and community with cultural sensitivity and respect (QSEN, 2019).
Nursing curricula should provide students with the opportunity to develop culturally sensitive care. The literature presents multiple innovative approaches that educators can use to teach students cultural competency (Smith, 2018). These approaches include role-play, journaling, clinical exchange programs, and service-learning (Smith, 2018). Service-learning in a diverse community is a teaching pedagogy that combines community engagement with specific objectives, preparation, and reflection that can explicitly enhance cultural competence for nursing students (Kohlbry, 2016).
Although the most effective teaching method for cultural competence in the nursing curriculum is not clearly identified, research has found service-learning to be effective in helping students deliver culturally appropriate care (Adamson, 2018; Amerson, 2012; Kohlbry, 2016; Long, 2016; Gower et al., 2019). Studies have shown that through participation in service-learning, students delivered care with empathy and compassion and performed patient-centered care to clients and families (Adamson, 2018; Coatsworth et al., 2016). In other studies, service-learning has shown an increase in students' self-efficacy, cultural knowledge, skills, attitudes, and cultural competence (Allen et al., 2013; Gower, 2019; Long, 2016). Kohlbry and Daugherty (2015) reported that through service-learning, students learned cultural communication and cultural confidence, built cultural knowledge and skill, and further recommended this pedagogy in nursing education to enhance cultural competence.
The purpose of this qualitative research study is to report the experiences of nursing students who participated in a service-learning project in Oaxaca, Mexico. Thus, the research question is: What is the impact of service-learning on nursing students delivering care to a diverse population?
Background of Research
Service-learning is a teaching pedagogy that combines learning goals and community service in a meaningful way. Students live, work, and engage in a diverse community where they gain experiential learning that enriches the experience by understanding cultural sensitivity and cultural competence (Bandy, 2019; Kohlbry, 2016). Cultural competency is enhanced when students spend time in a community living and caring for people (Gower et al., 2019).
The principal investigator (PI) of this research organized a service-learning experience for students through a religious organization in Oaxaca, Mexico. An invitation was emailed to nursing students in a baccalaureate nursing program in rural California to attend an informational session about service-learning. At the informational session, interested students were asked to submit an application to participate in the service-learning, the applications were reviewed by a committee of two, and accepted students were notified by email. Predeparture preparation for the service-learning occurred over 1 year.
The service-learning took place primarily in the small coastal town of Cacalotepec, Oaxaca. Modern accommodation was provided to the students by the organization at a cost. This service-learning was voluntary work, where students provided care in a medical clinic and three outlying villages, observed nurses at the local hospital, set up mobile clinics in the villages, and interacted with children in an orphanage. The care students delivered to adults and children in the community was focused on health promotion activities and education on chronic disease prevention and management.
The team on this service-learning consisted of a nurse, physician, physical therapist, pharmacist, school counselor, and the PI who is also an RN and was present for all activities. All students had the opportunity to work with each member on the team. Students journaled the experience and attended daily meetings with the PI (F.M.-B.) for reflection and debriefing.
The Process of Cultural Competence (Campinha-Bacote, 2002) is a framework used to guide the development of cultural competence of participants in this study. The essence of culturally competent care is attending to an individual, family, and community within the context of their culture (Campinha-Bacote, 2019). The assumption of this framework is that cultural competence is a process and not a one-time learning experience (Campinha-Bacote, 2019).
The framework has five constructs: cultural awareness, cultural knowledge, cultural skill, cultural encounter, and cultural desire (Campinha-Bacote, 2019). Cultural awareness occurs when health care professionals (HCPs) knowingly recognize their own culture to eliminate biases toward other cultures. Cultural knowledge takes place when HCPs procure thorough knowledge about another culture. Culture skill is to elicit information from clients by way of culturally appropriate comportment and through physical assessments. Cultural encounter ensues when HCPs have cultural exchanges with clients to amend beliefs and avoid stereotyping members of the culture. Cultural desire is the HCP's determination to engage in the process of gaining knowledge and understanding or another culture of actively seeking the encounter (Campinha-Bacote, 2019).
This culture of competence framework when used provides students a solid foundation to actively engage in deep meaningful learning of individuals' culture (Camphina-Bacote, 2002). The most important construct of this framework, cultural encounter, was exemplified in this study; nursing students were enthusiastic about living and caring for this diverse population in Mexico. Nursing students in this study shared their knowledge and skills with community members, while the community members in turn shared their culture, belief systems, perspective, and worldview. Table 1 provides more explanation of application of constructs.
Application of the Process of Cultural Competence Framework
This qualitative phenomenological study explored the experience of participants (nursing students) participating in service-learning in rural Mexico. The research methodology is based on phenomenology of Van Manen (1996). This exploratory approach was chosen as participants make sense of their unique perceptions and understanding of experiences without bias from the investigator and her experiences. The investigator makes generalizations based on the perspectives of the participants and searches for the essence of their lived experience. By using this methodology, the emerging experiences of the lived experience of nursing students who participated in this service-learning was explored in depth.
In using Van Manen's (1996) approach to provide a deep understanding of the meaning of the experience, the researcher applied these six activities:
- The researcher committed to use a phenomenon to increase understanding.
- Investigate the experience as it is lived, rather than building concepts.
- Think about the important themes that exemplify the phenomenon.
- Explain the phenomenon by writing and rewriting.
- Uphold a robust and oriented relation to the phenomenon.
- Offset the research context by ruminating the segments and the whole.
These activities allow the researcher to explore the data and uncover meanings in the data (Van Manen, 1996).
The investigator had volunteered at this facility in Mexico the previous year and had foreseen a rich cultural experience for nursing students. This study has a convenience sample of nursing students (juniors and seniors) enrolled in a baccalaureate nursing program. Research participants were recruited after being informed of the purpose of the study. Participants were assured of anonymity and confidentiality. Written consent was obtained from all participants. Ethics permission for the study was granted from the institutional review board at California State University, Chico. Twenty students participated in this service-learning with an immersion of 9 days in the community. The participants were mainly female, single, and 20 to 26 years old (Table 2).
Participants Demographics (N = 20)
The investigator conducted in-depth focus interviews to obtain rich, descriptive data of the lived experience of students that participated in this service-learning. There were two focus interviews done over a 2-year period. Both interviews took place in a conference room at the organization in Oaxaca at the end of the service-learning. Each interview lasted 90 minutes. Participants were asked questions from a script with 10 questions (Table 3). These 10 questions were based on the Campinha-Bacote model, a review of the literature, and the authors' experience in leading students on other service-learning trips. The responses were audio recorded and the data were transcribed verbatim into text by the PI.
Focus Interview Questions
The PI was immersed in the data by reading the transcript multiple times to discover meanings in the participants' experience. The PI recognized the value of every statement made by the participants, but meaningful themes that emerged were identified and labeled from the participants' voices for a wide understanding of the experience. The important recurring themes were then placed under major themes that reflected the essence of participants' experiences. After the themes were labeled, they were reexamined by the PI to ensure that appropriate descriptors were used, and the descriptors were changed for a more accurate description where necessary. Phenomenological themes derived are structures of experience that contributed to the complete experience. Central to data analysis is that the PI developed dialogue with the text instead of a structured coding approach. Data saturation was achieved with the second focus interview, and data triangulation was established through prolonged work with the participants during the service-learning. The PI reviewed the refined theme with an expert nurse who has been working in the community and hosting service-learning student groups for over 10 years. In addition, PI randomly chose six participants who substantiated the research findings.
Four themes emerged from data analysis of the participants' experience. The themes were common to all participants and reflected their perceived views. A discussion of each individual theme follows.
Theme 1: Value Communication
The primary language of all the participants is English, and the primary language of the clients in the community is Spanish. Participants who did not speak Spanish explained how they communicated with clients:
- Those of us who don't speak Spanish, we use lots of hand gestures. And we speak really slowly.
- Demonstrating to the patients also helps, like showing them to breathe in deeply.
- Using nonverbal communication.
All 20 participants acknowledged that they used the fellow students who are Spanish speaking as translators due to the language barrier.
- We have six bilingual classmates, so we used them as interpreters, which helped a lot.
- Yes we were so lucky to have so many translators. I feel like if we didn't have this many translators, we wouldn't have as good of an experience. We were able to turn to our classmates and be like “What are they saying?”
All participants acknowledged the importance of communicating to a client. One participant stated, “It amplifies how important the communication aspect is. A lot of my time in nursing school, I focus on the clinical and learning the theory. You really don't think about the importance of communicating to a client until there is a language barrier.” The participants expressed their appreciation of how the clients worked with them to overcome the language barrier. One participant said, “I feel like in the U.S., sometimes when a Hispanic person does not speak English, there is the feeling ‘Oh you're in America, you are supposed to be speaking English.’ Here in Oaxaca, that is not the case. The local people try to find another word for us to help us understand. The patients repeat it…and use sign language. It took six times for me to finally understand.” Another participant said, “I had a client today, I tried speaking to him in Spanish. When I finally got it, he said, ‘Yes! Yes! Yes!’ It's like you're a child saying your first word, they get so excited that you are trying to speak to them in Spanish and trying to understand them.” Only three of the 10 participants in the second interview were fluent in Spanish.
Here are some of the challenges they described encountering related to the language barrier:
- This made our work and travel difficult. On our travel days, we almost got separated twice due to misunderstanding of instructions. The language barrier also made delivering care to the clients more difficult. For example, something routine, such as vital signs, became challenging when trying to instruct patients. Without a translator, most of us weren't able to communicate with the patients.
- I think it's beneficial to have people on our team who speak Spanish.
The language barrier revealed to us the difficulty that exists when our patients don't speak English. And this makes me think how my Spanish speaking patients in the U.S. might feel.
One participant emphasized the importance of proper communication not only during this trip but upon returning home to the United States, as reflected in this statement:
When my patient does not speak English, I probably won't ever complain about using a translator ever again. Using an interpreter could turn a visit around, you might find out so much more that you would not have known had you not have someone to translate for you.
Theme 2: Understand Differences
When working with different cultures, it is important to appreciate different standpoints. It helps to dispel negative stereotypes and biases about groups of people. It also helps us to build bridges for trust, respect, and understanding. Here are some examples of how the participants expressed differences they experienced:
- You definitely see different values; it kind of opens our eyes to their perspective and why they do things the way they do.
- I have a different appreciation for where I live, we call it “Mini Mexico.” I never really understood why, until I came here; everything now makes sense. The stores are all the same as you see here [in Oaxaca]. And the way they carry things on their bikes to sell, the wall decor, the bright colors. It never made sense until I came here.
- I have been thinking about the different people and culture that we have seen in one small part of Mexico. We've seen two different major cultures and others that we probably haven't even noticed. We have to remember not to lump all Spanish-speaking people into one culture because they're not. Just like all White people in the United States are not all of the same culture.
- We have to treat people as individuals.
Another participant recognized that being different does not mean one is not intelligent:
I was thinking someone I work with at home [in the United States]. She speaks English well, but with an accent, you can tell that she's not from the U.S. Sometimes you think because someone doesn't speak like you do, you assume they're not intelligent; that is wrong.
There was a lot of poverty in the community we served, and the participants spoke to this: “Before this trip, I had never seen things in a developing country. And I feel like I really got to see that here. It's a really humbling experience.” The participants acknowledged how subgroups in their home country (the United States) might feel, stating:
- We've been in this place where we are the minority, we feel lost and overwhelmed at times, the language barrier, and being in a different environment we're not used to. I feel perhaps that's how minorities in the U.S. feel all the time.
- Getting to see yourself as a minority, is helpful to understand how other minority people [back home] might feel.
- We have a classmate who is a foreign student; sometimes I see her look up a word or she asks another classmate, “What does that mean?” And now it clicks to me that she's probably struggling a lot of time with English and it makes me want to try to help her more.
Another participant acknowledged how it might feel when a patient does not understand the native language: “I can only imagine how scared someone who is in the hospital and doesn't speak English. When the doctor comes in and explains what's going on, they don't understand. I think it would be very scary.
Theme 3: Provide Education
All participants had the opportunity to provide much needed education to the clients one-to-one and also in groups. Participants said:
- I feel like the clients knew so little and, believe it or not, just a little education goes such a long way. A lot of them did not show they understood some of the content taught, so we had to simplify things. It feels good to be able to provide them with education.
- Something as simple as education is life-changing for them and for us pretty rewarding.
- It felt so good that so many of us were teaching the patients about their diagnoses, such as diabetes. At one point the nurse ran off to take care of something and to just be able to work on our own to impart what was awesome. It's good experience for us as future nurses, we are not going to be able to do that ever again. Even the little things people that came in with…heartburn, or a cough. We have the knowledge from what we learned in nursing school and taught them, which was great.
The community members we served mostly work in the fields. The following are quotations from the participants:
- A lot of people came in with headaches, and we found out that it is just dehydration from working in the heat all day and not drinking enough water. A lot of our education focused on increasing water intake; it's a pretty big one around here.
- Most of the clients did not read and write in their native language, so there was thought in providing education in the right format.
- When teaching we used a lot of visual aids and less words. A lot of pictures for diabetes teaching. This was important because the clients did not know how to read or write.
- In our group education presentation, we drew and used bright colored markers. I did not realize we had so many artists in the group.
- We also used the translators so everything on our educational poster was in Spanish.
- In the clinic, we used premade pictures; they are great. We also drew pictures to teach—for example, giving instructions to take medicines three times per day, we drew pictures of sunrise, noon, and sunset on the pill bottle.
Theme 4: Appreciate Humanity
Participants identified the kindheartedness shown to them by the clients. They said:
- I like that pretty much everyone you meet says “good morning.” Sometimes I'm passing people and I'm in a different world, I have to catch myself, I'm like, “Oh he just said good morning to me.”
- People you don't know and probably are never going to see ever again, but they took the time to say good morning to you just because you were walking by.
The participants were touched by acts of kindness in the community and stated, “The people have nothing and would give you everything they have, it's heartwarming.” The participants also spoke about the fulfillment of giving to people who are less fortunate. “That first day here visiting the kids at the orphanage was when I felt so full of love and happiness. I wanted to just give those kids everything because that's how they made me feel, like the more I gave the more I would be happy and my heart would be full.” The clients appreciated the services provided to them, and the participants valued the gratitude expressed to them. The participants commented:
- Seeing the reaction to the care we provided, how much we affect those people and their lives, they leave so satisfied.
- They had tears in their eyes because we gave them vitamins. To us, that's nothing, to them it's huge.
Another participant spoke of the life-changing experience: “You might ask how could nine days be life changing. But I see much poverty, so much to be thankful for, so much gratitude from the people. I think I will always carry this experience.”
Discussion and Recommendations
This qualitative research study sought to explore the experiences of nursing students delivering care to a diverse population through participation in an international service-learning project. The four themes from the findings are: Value Communication, Provide Education, Understand Differences, and Appreciate Humanity. These themes suggest that the experience was effective in enhancing cultural sensitivity and cultural competence for nursing students.
In applying the process of cultural competence framework, nursing students provided care to a diverse population to enhance skills in cultural competence. This service-learning experience allowed nursing students to become familiar with the five constructs (cultural desire, cultural encounter, cultural awareness, cultural knowledge, and cultural skill) of cultural competency. In this study, cultural desire occurred as students actively sought and cared for clients in Oaxaca, Mexico; this demonstrates a genuine desire. Students participated in the experience by volition; they had the desire to move out of their comfort zone to learn about another culture. The enthusiasm shown by students' work with this cultural group was palpable (cultural desire). Students were committed to have this cultural experience and funded the trip through personal funds. Of all the constructs in the process of the cultural competence framework, cultural encounter is the principal foundation in building cultural competency (Campinha-Bacote, 2019). An example of how students learned cultural awareness was in teaching clients: When they receive a head nod, students realized this was an acknowledgment of the conversation only. Cultural knowledge for the patients' beliefs (such as religion) was important for students to acknowledge in building trust and compliance with the clients. Cultural skill was applied when students used modesty and appropriate communication in performing physical assessments with female clients.
In this service-learning experience, students immersed in the culture. This included living, working, and socializing in the community. Although short term, this immersion enhanced learning of appropriate communication skills, specific cultural values and beliefs, and the effect on health. This process of cultural competency does not end here, but rather students have to continue working with diverse communities to develop and cultivate the necessary skills over time as they move into the nursing profession (Hutchins et al., 2014; Phillips et al., 2017).
Service-learning is beneficial to students as they work toward delivering culturally sensitive care. Nursing students who participated in immersion experiences also felt more prepared to care for patients of different cultures and even felt more equipped to care for patients of diverse cultures and felt more secure caring for patients when there were language barriers (Allen et al., 2013; Long, 2016). Students reported using language skills acquired during the immersion experience when caring for patients (Allen et al., 2013). Communication skills are enhanced when students travel to countries where the host language is different, as seen in this study and supported in the literature (Gower et al., 2019). When the participants in this study encountered a language barrier, they found effective ways to communicate, which is a key component of culturally sensitive care. Effective communication is known to improve patient satisfaction, adherence to treatment, and health outcomes (Almutairi, 2015).
In this study, students were reminded of the essence in humanity, mutual respect and appreciation for each other, and how connected we are as human beings. As nurses, it important to recognize the connection of individuals with each other, resources, and the larger human community. Adamson (2018) reported that when students spent time caring for people from another culture, this helped them personally and professionally in building cultural sensitivity and cultural competence. Although there were cultural differences, nursing students acknowledged this and provided respectful and compassionate care for other human beings. When exposed to another culture, students develop a mindset to understand and respect other human beings and deliver compassionate care (Adamson, 2018).
Along with compassion is the need to provide education to people of diverse groups to help them maintain good health. As nurses, it is important to assess and understand the literacy level of clients so that appropriate education can be provided. The students in this study provided education in the format that was appropriate for this diverse community. It must be understood that social determinants such as lower levels of education and low health literacy can disproportionately affect minority groups and thus can contribute to the poorer health outcomes (Betancourt et al., 2014; McKenna et al., 2017).
The Agency for Healthcare Research and Quality (2014) has recognized that culturally diverse groups experience lower health disparities and is working to improve health outcomes for these individuals. One way to do so is through the provision of culturally appropriate and unbiased care to diverse groups. Culturally competent care entails respecting the diversity of patients and cultural influences that can affect care, such as language, communication, attitudes, beliefs, and behaviors. Personalizing health care services to a patient's culture can bring about positive health outcomes for diverse populations (Agency for Healthcare Research and Quality, 2014). Increased cultural competence has been linked to increased patient satisfaction, treatment adherence, information seeking and sharing, and health outcomes (Jongen et al., 2018). The U.S. Department of Health and Human Services, Office of Minority Health (2019) endorses culturally competent care by establishing the National Standards for Culturally and Linguistically Appropriate Services (CLAS). The national CLAS provides a blueprint with standards to help organizations improve services to culturally diverse individuals, reduce health disparity, and achieve health equity (Office of Minority Health, 2019).
As a teaching pedagogy, international service-learning gives nursing students a space for inquiry, dialogue, and reflection, where questions about a culture are answered (Samuels, 2014). Understanding culture is essential to build cultural sensitivity and cultural competency for nursing students entering the nursing profession.
The essence of communication was reinforced in this study. When a language barrier exists, nonverbal communication provided important cues, and use of a translator cannot be underestimated. Translation of the treatment in the clients' native language promote better understanding and adherence. HCPs cannot assume clients' literacy level, but rather make an active assessment and tailor the information to that literacy level.
When working with a specific cultural group, it should not be assumed that everyone is alike. There are many different intersectionality factors that must be considered—for example, gender and socioeconomic status. This helps HCPs understand that each client has unique needs and to deliver patient centered care. Because service-learning exposes students to lives that are profoundly different than theirs (in social and economic ways), this reinforces the notion that other conditions influence health, behaviors, and disparities, and it is important to create space for inquiry, dialogue, and reflection surrounding these issues.
Development of cultural competency is a process. It takes time to learn a new culture, and patience is required. When learning a new culture, the importance of working with a team member who has prior experience with the cultural group is invaluable. The global concept of sustainability resonated in this service-learning experience with connection of people to the environment and the global community. Above all, learning to appreciate the humanity in us all by giving and receiving was powerful.
The increasingly diverse population in the United States, along with a need to reduce health disparity in diverse groups, makes delivering culturally appropriate care crucial to nursing care. Service-learning is a transformative educational experience that exposes students to diverse lives that are different from their own in a manner that acknowledges the cultural, social, and economic conditions affecting health. It is a pedagogy that should be supported in the nursing curriculum to enhance cultural competency.
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- U.S. Department of Health and Human Services, Office of Minority Health. (2018). The national CLAS standards. https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=2&lvlid=53
- U.S. Department of Health and Human Services, Office of Minority Health. (2019). Cultural and linguistic competency. https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=1&lvlid=6
- Van Manen, M. (1996). Researching lived experience, human science for an action sensitive pedagogy. State University of New York.
Application of the Process of Cultural Competence Framework
|Cultural awareness||Nursing students examined their own biases toward other cultures and examined their own culture in depth|
|Cultural knowledge||Nursing students sought information about the clients in Mexico before and during the experience|
|Cultural skill||All students had the opportunity and ability to participate in a cultural assessment of the client's presenting problem|
|Cultural encounter||Pivotal construct. All students engaged in face-to-face cultural interactions and other encounters with clients|
|Cultural desire||By volition, students had the motivation had to participate in the process to become culturally aware, knowledgeable, and skillful|
Participants Demographics (N = 20)
|Characteristic||Year 1 (2016–2017)||Year 2 (2017–2018)|
|Semester in nursing program|
| Personal funds||10||0|
| Personal funds and grant||0||10|
Focus Interview Questions
Had you ever traveled outside of the United States? If so, for what purpose?
Do you speak the language of the population you serve?
What ways were you able to overcome the language barrier?
What are some of the things you learned on this trip?
How can you apply some of what you learned to better understand your community?
How can you apply some of what you learned to your future career?
How does this trip excite your passion for helping others?
What is the most rewarding experience you have had on this trip?
What is your least favorite experience of this trip?
How beneficial would this trip be for other students?